Person-Centered Positive Behavior Support Plan (PC-PBS) Report
Scoring Criteria & Checklist (Rev. 3-5-07) P. 1 of 8
Name: __________________ Case Name: _________________ Case #: ___ Rater: _______ Date: ______
Critical Features
Note: The plan needs to meet all of the critical features listed below, and needs to obtain a
score of 2 for items # 27, 36, 37,41, & 42 in order to be considered for passing
CF1
CF2
CF3
CF4
CF5
Interventions selected employ validated procedures
Preferred lifestyle goals attempt to increase quality of life, not simply maintain it
The plan is designed to make a meaningful positive difference in the life of the individual
The plan clearly reflects the values and beliefs (philosophy, standards, & foundation) of KIPBS
The plan has obtained a score of 2 on items 27, 36, 37, 41, & 42
Y
Y
Y
Y
Y
N
N
N
N
N
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
Instructions - Please rate each of the following questions by circling either 0, 1, or 2 according to each question’s criteria
IDENTIFYING INFORMATION
1.
Identifying info. is complete (facilitator name, consumer name, address, DOB, age, contacts,
referral source)
2 = All identifying information is provided including name of person writing the report, consumer’s name, address, DOB,
age, contacts, and referral source
1 = Some of the above identifying information is included but not all
0 = With the exception of the consumer’s name, there is no identifying information included that is relevant to the plan
GENERAL INFORMATION
Consumer Information – (GENERAL Information)
2.
A brief history of the consumer’s life is provided
2 = There is a description of the consumer’s history, which includes health issues, behavioral issues, diagnoses, living
situations, moves, and community involvement. If particular events do not apply, it is so stated.
1 = Some events are described, or there is a diagnosis provided, but the information is limited
0 = There is no information provided regarding the consumer’s history
3.
Important places for the consumer at school/work, home, and in the community are described
2 = Important places for the consumer, at school/work, home and in the community are described in general
1 = Some places are listed, but the information is limited (e.g. does not address each setting listed above)
0 = There is no information provided regarding important places for the consumer
4.
Opportunities for the consumer to interact with friends and/or family are described
2 = Quality and frequency of friendships (may include paid supports) and/or family interactions are discussed
1 = Friendships and/or family relationships are mentioned but there is no description regarding the quality or frequency of
the relationships
0 = There is no information provided regarding the consumer’s opportunities to interact with friends or family members
5.
The consumer’s strengths are described
2 = Several specific consumer’s positive behaviors, skills, and strengths are described
1 = Some positive behaviors, skills, or strengths are described but the information is limited
0 = There is no information provided regarding the consumer’s positive behaviors, skills, or strengths
6.
The consumer’s preferred method of communication is described
2 = The consumer’s mode of communication is described as well as any possible issues related to communication and
problem behavior
1 = Incomplete information is provided regarding the consumer’s mode of communication
0 = There is no information provided regarding the consumer’s mode of communication or strategies related to
communication
7.
Opportunities for choice in the consumer’s current environment are described
2 = There is a specific description of the consumer’s opportunities to make choices in at least 3 areas throughout the day.
If there are areas in which opportunities for choice are limited, these are listed. (Need to mention “choice”)
1 = The description of opportunities to make choices addresses less than 3 areas. (Need to mention “choice”)
0 = The issue of opportunities to make choices is not addressed (there is not mention “choice”).
8.
Current health and physiology issues are described
2 = Current health status, including chronic and/or acute medical issues, medication, and necessary adaptive equipment, is
described. If the consumer is in good health, it is so stated.
1 = Incomplete information is provided regarding current health status issues, including medication information
0 = There is no information regarding current health status
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Person-Centered Positive Behavior Support Plan (PC-PBS) Report
Scoring Criteria & Checklist (Rev. 3-5-07) P. 2 of 8
9.
Mobility (motor and transportation) issues are described
2 = The consumer’s abilities to mobilize themselves physically and obtain transportation to different activities (e.g., work,
school, church) are described
1 = Some information is provided regarding the consumer’s mobility and transportation skills, but they are not completely
addressed
0 = There is no information provided regarding the consumer’s transportation or mobility skills
10.
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
Current schedules and routines are described (quality, predictability)
2 = There is a general description of the person’s daily schedule and routines, which includes quality, choice, variety, and
predictability, in general
1 = There is some information provided regarding regularly scheduled activities but there is no mention of how
predictable they are or how enjoyable they are
0 = There is no information provided regarding the consumer’s daily activity schedule
Reason For Referral
11.
Behavioral and/or environmental issues are identified
2 = A detailed description of the consumer’s problem behavior and the environmental context in which it occurs is
provided
1 = A limited description of the consumer’s problem behavior is provided, but no information is provided about the
contexts or situations in which it occurs, or why it is a problem
0 = There is no information provided regarding why the person has been referred to for services
PART 1 – ASSESSMENT
Understanding Consumer Preferred Future Lifestyle – (SPECIFIC Information)
12.
Planning and assessment participants are listed
2 = Planning and assessment participants’ names and their functions are listed
1 = There is a description of who participated in the planning and assessment, but it is incomplete (either not all
participants are listed or their function is unknown)
0 = There is no mention about who participated in the planning and assessment
13.
Surveys, interviews, and other tools to collect Preferred Future Lifestyle info are described
2 = For each tool used, there is a description of (1) the tool so that any reader may have an idea of the type of measures
gathered and (2) what the results were. If necessary, results are interpreted so that the reader knows what they mean.
1 = There is a description but not from each tool used, or the descriptions are incomplete (e.g., results are listed without a
reference range to compare them to)
0 = The tools used are not described or they are listed but the results are not provided
14.
A global statement of the consumer’s dreams is made
2 = There is a global statement about what the consumer’s dreams for the future are
1 = There is a statement about what the consumer’s dreams for the future are, but it is not very clear
0 = There is no mention about what the consumer’s dreams for the future are
15.
Type of preferred living setting for the consumer is described
2 = The consumer’s preferred living setting is clearly identified and there is a statement regarding how this information
was gathered
1 = The consumer’s preferred living setting is identified but there is no information about how this was assessed
0 = The consumer’s preferred living setting is not identified
16.
With whom the consumer wants to live is clearly stated
2 = Specific people or type of people the consumer wants to live with are clearly identified and there is a statement
regarding how this information was gathered
1 = With whom the consumer wants to live is identified but there is no information about how this was assessed
0 = With whom the consumer wants to live is not identified
17.
With whom the consumer wants to socialize is clearly stated
2 = Specific people the consumer wants to socialize with are clearly identified and there is a statement regarding how this
information was gathered
1 = With whom the consumer wants to socialize is identified but there is no information about how this was assessed
0 = With whom the consumer wants to socialize is not identified
18.
What work or school activities the consumer wants to do are described
2 = Specific work or school valued activities the consumer wants to engage in are clearly identified and there is a
statement regarding how this information was gathered
1 = What work or valued activities the consumer wants to engage in are identified but there is no information about how
this was assessed
0 = What work or valued activities the consumer wants to engage in are not identified
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Person-Centered Positive Behavior Support Plan (PC-PBS) Report
Scoring Criteria & Checklist (Rev. 3-5-07) P. 3 of 8
19.
Social, leisure, or religious activities the consumer wants to participate in are described
2 = Specific social, leisure, or religious activities the consumer wants to participate in are clearly identified and there is a
statement regarding how this information was gathered
1 = What social, leisure, or religious activities the consumer wants to participate in are identified but there is no
information about how this was assessed
0 = What social, leisure, or religious activities the consumer wants to participate in are not identified
20.
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
Barriers to achieving Preferred Future Lifestyle are described
2 = Possible barriers for the consumer to achieve his/her Preferred Future Lifestyle are identified, there is a statement
regarding why it is thought that this may be a barrier and for what area this it may be a barrier
1 = Possible barriers for the consumer to achieve his/her Preferred Future Lifestyle are identified, but there is not mention
as to why it is thought that this may be a barrier or for what area this it may be a barrier
0 = Possible barriers for the consumer to achieve his/her Preferred Future Lifestyle are not identified
Functional Assessment
21.
Indirect assessment data include at least 2 of the following (tools used & results are described):
□ Caretaker interviews
□ Record reviews
□ Preferred Future Lifestyle information
□ Assessment tools used to collect quality of life, setting events, & other related information
2 = Results from at least 2 of the information gathering methods listed above are described. If specific tools are used,
these are described, and their results are explained (e.g., mood scales).
1 = All the information is provided regarding results from only one of the assessment methods listed above, or results
from tools used are explained but the tools themselves are not described, or results are listed but not explained.
0 = No information regarding results from any of the assessment methods listed above is provided (even if it is listed that
such assessments were conducted)
22.
Data from 3-5 student conducted direct observations are described
2 = The student conducted three or more observations of the consumer, and the observations are described or the data are
provided
1 = The student conducted less than three observations of the consumer and the observations are described or the data are
provided
0 = No observations were conducted or observations are not described and the data for such are not provided
23.
Problem behaviors are operationally defined; definitions are clear
2 = For each problem behavior targeted (or behavior class) there is a clear operational definition, devoid of subjective
and/or circular terms
1 = There is a definition, but it is unclear or incomplete or only some of the targeted problem behaviors are defined
0 = There is no definition provided regarding any problem behavior
24.
Baseline data are clearly graphed (include labels, axis values, titles, and legend)
2 = Baseline data are clearly graphed (no more than 3 behaviors in one graph), and the graph provided includes labels,
axis values, titles and a legend
1 = Baseline data are clearly graphed (no more than 3 behaviors in one graph) and the graph has some but not all of its
components
0 = Baseline data are not graphed or the graph is not clear (more than 3 behaviors in one graph)
25.
All direct assessment measures and data sources are described
2 = All direct assessment measures used (e.g. observations, ABC Chart) and conditions under which they were conducted
are described, and results are explained
1 = There is a description of the assessment measures used and their results, but it is incomplete – results are not provided
for all assessment measures used or the description provided is incomplete (e.g., data are listed without a reference)
0 = The assessment measures are not described or they are listed but the results are not provided
26.
Hypothesis statement is provided for each function of the problem behavior(s)
2 = A hypothesis is described for every function of the problem behavior(s) listed (or behavior class). If multiple
behaviors serve the same function, they can be listed together. If the same behavior serves different functions, there
are separate hypothesis statements for each function.
1 = A hypothesis is described for some but not all of the functions and/or problem behaviors (or behavior class)
0 = There is no hypothesis statement
*27.
Data to support each hypothesis statement are presented
2 = There are data provided in some format (graph, table, list, interview summary) that specifically support each
hypothesis statement
1 = There are data provided, but it is unclear whether they support a specific hypothesis or not
0 = Either there are no data presented or the data that are presented do not support the hypotheses listed
IDENTIFYING INFORMATION, GENERAL INFORMATION, & PART 1 – ASSESSMENT
Total Points Earned (Items 1-27) = __________
PERCENT = [ ____________ / 54] X 100% = __________ %
(Total Points Earned)
3 of 8
Person-Centered Positive Behavior Support Plan (PC-PBS) Report
Scoring Criteria & Checklist (Rev. 3-5-07) P. 4 of 8
Name: __________________ Case Name: _______________ Case #: ___ Rater: _______ Date: ______
Instructions - Please rate each of the following questions by circling either 0, 1, or 2 according to each question’s criteria
PART 2 – INTERVENTIONS AND SUPPORTS
Preferred Lifestyle Interventions
28.
Goals or skills to be achieved are described
2 = The goals or skills to be achieved are clearly described
1 = The goals or skills to be achieved are listed but are not clearly described
0 = There is no mention about the goals or skills to be achieved
29.
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
Plan outlines how achievement of goals or skills will be assessed
2 = Exactly which data are to be collected, and how they will be collected, to assess goal achievement, is stated
1 = It is unclear which data will be collected or how they will be collected or which will be used to assess goal achievement
0 = There is no mention of data collection of any kind to assess goal achievement
34.
1
Extra services and supports needed to assist the consumer to achieve goals are described
2 = Additional services and supports needed to assist the consumer achieve his/her goals are clearly identified and
described. If none are needed, it is so stated.
1 = Additional services and supports needed to assist the consumer achieve his/her goals are identified but not described
(simply listed), or is described but the description is unclear
0 = Additional services and supports needed to assist the consumer achieve his/her goals are not addressed
33.
2
Materials, equipment, and/or assistive technology needed to assist the consumer to achieve
goals are described
2 = The materials, equipment, and/or assistive technology needed to assist the consumer achieve his/her goals are clearly
identified and described. If nothing is needed, it is so stated.
1 = The materials, equipment, and/or assistive technology needed to assist the consumer achieve his/her goals are
identified but not described (simply listed), or is described but the description is unclear
0 = The materials, equipment, and/or assistive technology needed to assist the consumer achieve his/her goals are not
addressed
32.
0
Caretaker training needed to assist the consumer to achieve goals is described
2 = The training needed to assist the consumer achieve his/her goals is clearly identified and described. If no training is
needed, it is so stated.
1 = The training needed to assist the consumer achieve his/her goals is identified but not described (simply listed), or is
described but the description is unclear
0 = The training needed to assist the consumer achieve his/her goals is not addressed
31.
1
Activities needed to assist the consumer to achieve goals are described
2 = The activities needed to assist the consumer achieve his/her goals are clearly identified and described
1 = The activities needed to assist the consumer achieve his/her goals are identified but not described (simply listed), or
are described but the description is unclear
0 = The activities needed to assist the consumer achieve his/her goals are not addressed
30.
2
Plan outlines how changes in the consumer’s Preferred Future Lifestyle will be evaluated
2 = Exactly what information will be collected and how, to determine changes in the consumer’s Preferred Future Lifestyle
is stated
1 = It is unclear how changes in the consumer’s Preferred Future Lifestyle will be assessed
0 = There is no mention of how changes in the consumer’s Preferred Future Lifestyle will be assessed
Function Based Interventions
35.
Rationales for intervention selection are stated
2 = For each intervention component, there is a rationale that relates to the behavior
1 = There are some rationales provided, but not for all the intervention components, or it is unclear how the rationales
relate to the behavior
0 = There are no rationales provided regarding intervention components
*36.
Possible function of problem behavior is addressed
2 = The interventions selected include a description of how they address all the function(s) of the problem behavior(s)
1 = The interventions selected do not completely address the function(s) of the problem behavior(s)
0 = The interventions selected are unrelated to the function(s) of problem behavior(s)
*37.
Teaching of adaptive skills as replacement behavior is included
2 = There is a portion of the intervention that addresses reinforcing or teaching adaptive skills to replace problem behavior
1 = The intervention plan notes that replacement behaviors should be reinforced but there is no description of how this
would be done or there is no description of specific replacement behaviors to target
0 = There is no mention of target replacement behavior
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Person-Centered Positive Behavior Support Plan (PC-PBS) Report
Scoring Criteria & Checklist (Rev. 3-5-07) P. 5 of 8
38.
Replacement behaviors are operationally defined
2 = For each replacement behavior there is a clear operational definition that is appropriate for any caretaker to use to
collect direct observation data
1 = There is a definition but it is unclear or incomplete or only some of the replacement behaviors are defined
0 = There is no definition provided regarding any replacement behavior
39.
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
Each part of the hypothesis statement (setting event, antecedent, behavior, & consequence) is
addressed
2 = There are specific components of the intervention that address each portion of the hypothesis statement and include
setting events, antecedents, teaching new skills, and consequences of the behavior
1 = Some of the components of the hypothesis statement are addressed but not all
0 = The intervention does not address the hypothesis statement at all
40.
2
Environmental interventions address at least 3 of the following:
□ Opportunities for choice
□ Schedule predictability
□ Instructional/ interaction approaches
□ Prompts for appropriate behavior
□ School or day program curriculum
2 = The intervention addresses at least three of the above listed environmental issues
1 = The intervention addresses less than one or two of the above listed environmental issues
0 = The intervention does not address any of the above listed environmental issues
*41.
Minimizing positive and/or negative reinforcement for problem behavior is included
2 = The intervention specifically describes how to minimize positive or negative reinforcement for the problem behavior
1 = The intervention notes that reinforcement for problem behavior should be minimized but does not describe how this
should be done
0 = The intervention does not include a component to minimize positive or negative reinforcement for the problem
behavior
*42.
Selecting effective reinforcers and/or maximizing positive reinforcement for appropriate
behavior is included
2 = The intervention includes specific reinforcers for appropriate behavior and describes how/when these will be used
1 = The intervention includes a positive reinforcement component but it is too general or does not describe how to
implement it (e.g. Praise appropriate behavior)
0 = The intervention does not include a description of any positive reinforcers that could be used
43.
Safety/emergency procedures for what to do if/when crisis occurs is addressed
2 = There is a specific crisis intervention plan described and the components are appropriate given the severity of the
behavior. If safety/emergency procedures are not necessary, it is so stated.
1 = There is a crisis plan noted but the description is incomplete or it is inappropriate given the severity of the behavior
0 = There is no crisis plan noted and the severity of the behavior warrants one
44.
Training needs are addressed
2 = Who will train caretakers about program implementation and data collection, and what to do if additional training or
support is needed is specifically stated
1 = Training issues are noted but there is no explicit plan
0 = There is no mention of training or issues of support for the caretakers
45.
Measurement method of each target behavior is described (including replacement behaviors if
data are collected on them)
2 = The data collection method for each target behavior is described
1 = Mention is made that data will be collected on the target behavior but there is no concrete description of the data
collection method that will be used, or there is no description for all of the behaviors targeted
0 = There is no description of how any target behavior will be measured
46.
What data will be gathered for intervention effectiveness assessment is described
2 = Exactly which data are to be collected, and how they will be collected, to assess intervention effectiveness, is stated
1 = It is unclear which data collected will be used for intervention effectiveness assessment, or it is unclear how these data
will be collected
0 = There is no mention of data collection of any kind to assess intervention effectiveness
47.
Training needs are identified and/or system of support is established
2 = There is an explicit plan to address the abilities of the caretakers regarding the types of additional training they may
need or other issues related to supporting the consumer
1 = Training issues are noted but there is no explicit plan for addressing them or it is unclear how the plan address the
needs of the caretakers
0 = There is no mention of training or issues of support for the caretakers in the plan
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Person-Centered Positive Behavior Support Plan (PC-PBS) Report
Scoring Criteria & Checklist (Rev. 3-5-07) P. 6 of 8
General Intervention Considerations/ Contextual Fit
48.
Resources needed are described including time requirements for implementation
2 = Possible resources that caretakers may need, including having enough time to provide adequate support to the
consumer, are described, and there is a plan for obtaining those resources
1 = It is noted that caretakers may need additional supports but there are no resources or plan provided
0 = The plan does not address resources or support needs for caretakers
49.
Process for monitoring the intervention plan is described:
□ Timeline for meetings □ What needs to be done □ When
□ By whom (responsibilities)
2 = There is a specific process described for the team to meet and for specific individuals to monitor the plan
1 = It is noted that the plan will be monitored regularly, but there are no specific details regarding how it will be done
0 = There is no indication that the plan will be monitored at all
51.
1
0
2
1
0
2
1
0
2
1
0
Financial costs and limitations related to interventions are discussed
2 = Possible financial costs of interventions are identified and either there is a specific plan of taking care of those costs,
or if costs are too great, there is a statement regarding how these costs will limit the interventions. If interventions do
not require any financial contributions, it is so stated
1 = It is noted that there may be possible financial costs, but these are not specified, or there is not plan as to taking care of
these costs, or if costs are too great, how the impact of these costs on interventions is not stated
0 = The plan does not address financial costs
50.
2
Evidence that values/expectations of team members are considered
2 = There is some description provided of those issues that are important to the caretakers regarding the intervention or
data collection and the plan is modified or written to address these concerns
1 = Issues may be noted regarding values or expectations of team members but there is no indication of how they are
addressed in the plan
0 = The values/expectations of the team are not discussed
PART 2 – INTERVENTIONS AND SUPPORTS
Total Points Earned (Items 28-51) = __________
PERCENT = [ ____________ / 48] X 100% = __________ %
(Total Points Earned)
6 of 8
Person-Centered Positive Behavior Support Plan (PC-PBS) Report
Scoring Criteria & Checklist (Rev. 3-5-07) P. 7 of 8
Name: __________________ Case Name: _______________ Case #: ___ Rater: _______ Date: ______
Instructions - Please rate each of the following questions by circling either 0, 1, or 2 according to each question’s criteria
PART 3 – FOLLOW-UP
Preferred Lifestyle Interventions Follow-up
52.
Evaluation of achievement of goals or skills includes (at least 1):
□ Number of goals or skills achieved □ Other measures of achievement of goals or skills
2 = For each goal, there is a measure of some sort provided, regarding goal status
1 = Goal status is discussed, but there is not specific measure provided, or not all goals are addressed
0 = There is no mention of goal status
53.
Evaluation of changes in the consumer’s Preferred Future Lifestyle includes a statement
regarding the status of each of the following:
□ Type of preferred living setting
□ With whom the consumer wants to live
□ With whom the consumer wants to socialize
□ What work or other valued activity the consumer wants to do
□ What social, leisure, religious or other activities the consumer wants to participate in
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2 = For each issue listed, there is a statement regarding its current status
1 = There is a statement regarding current status of some of the issues listed, but not all
0 = Current status of issues listed is not addressed
54.
If there is evidence of changes in Preferred Future Lifestyle, achievement of goals, or that a
service provided is unresponsive, there is a plan for revisions to reflect these changes
2 = If changes have occurred in the areas listed, either the plan has already been revised to reflect those changes, or there
is a plan for making those revisions. If changes in the areas listed have not occurred, it is so stated
1 = It is noted that changes have occurred in the listed areas, but there are no plans for making revisions
0 = There is no mention regarding changes in the listed areas
Function Based Interventions Follow-up
55.
Baseline and intervention data for each target behavior are graphed
2 = All target behaviors are graphed and graph(s) depict(s) both baseline and intervention data
1 = There is a graph, but not all target behaviors are graphed, or the graph does not include either baseline or intervention
data
0 = There is no graph
56.
Graphs are clear (include labels, axis values, titles, and legend)
2 = The graph provided includes labels, axis values, titles and a legend
1 = The graph has some but not all of its components
0 = There is no graph or it the graph is not clear
57.
Indirect or direct measures of replacement behavior are provided
2 = Either direct or indirect measures of changes in the replacement behavior are provided
1 = Replacement behavior change is discussed, but there is no mention of actual direct or indirect measures of it
0 = There is no mention of replacement behavior change
58.
A statement regarding the effectiveness of interventions is made
2 = A summary type of statement regarding whether or not the interventions were effective at changing the behavior is
provided
1 = Data are mentioned, or results are mentioned, but there is no clear summary statement as to the actual effectiveness of
the interventions
0 = There is no summary statement regarding the effectiveness of the interventions
59.
Data provided support statement(s) regarding the effectiveness of interventions
2 = There are data provided in some format (graph, table, list,) that specifically support the statements made regarding
intervention effectiveness
1 = There are data provided, but it is unclear whether they support the statements made regarding intervention
effectiveness
0 = Either there are no data presented or the data that are presented do not support the statements made regarding
intervention effectiveness
7 of 8
Person-Centered Positive Behavior Support Plan (PC-PBS) Report
Scoring Criteria & Checklist (Rev. 3-5-07) P. 8 of 8
Continuous Evaluation
60.
Measures to be gathered for continued evaluation include both direct and indirect measures
2 = There is an evaluation system described that includes measuring problem behavior using both direct and indirect
assessment tools on a regular basis
1 = The plan indicates that only direct or indirect tools will be used to monitor progress, but does not state how
0 = There is no indication of the kind of tools or the frequency with which they would be used to monitor the plan
61.
Process for continuing to monitor the intervention plan is described:
□ Timeline for meetings □ What needs to be done □ When □ By whom (responsibilities)
2 = There is a specific process described for the team to meet and for specific individuals to monitor the plan
1 = It is noted that the plan will be monitored regularly, but there are no specific details regarding how it will be done
0 = There is no indication that the plan will be monitored at all
62.
Plan for sustainability includes:
□ Plan for transitions or major setting events
and/or
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
□ Training plan for new staff
2 = There is a long term plan for how the intervention will be kept going including addressing possible transitions or
major life changes
1 = It is mentioned that the implementation of the intervention plan will continue but there is no indication of how
possible transitions or major life changes will be addressed
0 = There is no mention of long-term plans for sustaining the intervention
PART 4 – ATTACHMENTS
63.
Sample fidelity checklist
2 = Sample fidelity checklist is included and accurately portrays program procedures
1 = Sample fidelity checklist is included but is inaccurate, incomplete, or unclear
0 = Sample fidelity checklist is not included
KIPBS Intervention & Supports Plan At-A-Glance sheet (not need to be labeled “KIPBS”)
64.
2 = At-A-Glance sheet is included and accurately portrays information and important program information (i.e. Do’s and
Don’ts)
1 = At-A-Glance sheet is included but is inaccurate, incomplete, unclear, or only addresses what to do when problem
behavior occurs
0 = At-A-Glance sheet is not included
65.
All supporting materials necessary for a full understanding of the report are included:
□ Data sheets □ Data summaries □ Questionnaires / Interviews / Surveys □ Other
2 = Questionnaires, data files, graphs, and other pertinent materials necessary for full understanding of the report, are
included or report is self-sustaining (i.e. no other materials are needed for full understanding)
1 = Some, but not all of the pertinent materials are included (e.g. graphs, but no data sheets)
0 = There were no supporting materials provided, and these are necessary for full understanding of the report
66.
Contextual Fit Survey
2 = Completed Contextual Fit surveys are included for at least 2 different team members (2 separate surveys)
1 = Completed Contextual Fit survey is included for only one team member
0 = There were no completed Contextual Fit surveys
67.
Quality of Life Evaluation Survey
2 = Completed Quality of Life Evaluation surveys are included for at least 2 different team members (2 separate surveys)
1 = Completed Quality of Life Evaluation survey is included for only one team member
0 = There were no completed Quality of Life Evaluation surveys
68.
PCP Satisfaction Survey
2 = Completed PCP Satisfaction surveys are included for at least 2 different team members (2 separate surveys)
1 = Completed PCP Satisfaction survey is included for only one team member
0 = There were no completed PCP Satisfaction surveys
PART 3 – FOLLOW-UP & PART 4 – ATTACHMENTS
Total Points Earned (Items 52-68) = __________
PERCENT = [ ____________ / 34] X 100% = __________ %
(Total Points Earned)
ENTIRE CASE STUDY
Total Points Earned (Items 1-68) = __________
PERCENT = [ ____________ / 136] X 100% = __________ %
(Total Points Earned)
KIPBS PC- PBS GENERAL REPORT FORMATTING
Y
Y
N
N
Pages are numbered
Report looks professional (no typos, no acronyms, little jargon and professional language)
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